Antisepsis in the Time of Antibiotics: Following in the Footsteps of John Snow and Joseph Lister
If Joseph Lister, founding father of antiseptic surgery, were alive today, he would be pleased with the low SSI rate today compared with 1867.4 Undoubtedly he would have applied his antiseptic protocols, including carbolic acid, not only to the surgical field and instruments but also to the anesthesia work area and equipment if they had existed in his day. However, in his era, there were no laryngoscopes, bronchoscopes, or endotracheal tubes to pass through bacteria-rich oral and nasal cavities, no spinal or epidural needles or central venous catheters to disrupt the integument, and no anesthesia machines to contaminate. Following in the footsteps of Lister, the Dartmouth group demonstrated that improved hand hygiene by anesthesia providers reduced HCAIs at their institution in their study patients.3 In this issue of Anesthesia & Analgesia, this group goes on to document anesthesia work area and IV stopcock contamination by anesthesia providers in and between operating rooms and between the first and second case in the same operating room, despite application of hand hygiene and anesthesia work area antisepsis protocols typical in modern operating rooms.5
Most anesthesiologists and their quality of care arbiters currently believe that the major contribution of the anesthesia team to the reduction of HCAIs relates to antimicrobial prophylaxis. Unfortunately, approximately 5% of surgical patients continue to experience SSIs despite timely administration of the appropriate antibiotic. In one recent study, intensifying the already rigorous intraoperative antisepsis protocol for surgeons did not reduce SSIs.6 In another, surgical glove perforation did not increase SSIs in patients who received antibiotics.7 If we have reached a plateau in our attempts to lower the SSI rate because we have gone as far as we reasonably can with surgical antisepsis and antimicrobial prophylaxis, then the remaining targets are the patient and the anesthesia provider. Does the work of Koff, Loftus, and others suggest that anesthesia providers have become the typhoid Marys and Johns of the 21st century?8,9 We think these monikers are premature until 4 issues are addressed and resolved: contamination as a surrogate marker versus cause of infection, reproducibility of data, completeness of the data, and consequences of proposed changes in protocols.
Contamination of surgical gloves, instruments, and anesthesia equipment has been demonstrated many times as a function of time from the last cleansing or opening to air and exposure to activity by health care personnel or patients.10–12 However, contamination is not equivalent to infection.